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Attitudes of pediatric nurses facing HIV risk
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Vol. 42, No. 3, pp. 463-469. 1996 Copyright © 1996 ElsevierScienceLtd Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00
Soc. Sci. Med.
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RESEARCH NOTE A T T I T U D E S OF P E D I A T R I C N U R S E S F A C I N G HIV RISK N A N C Y F. B E R K O W I T Z ~ and R O N A L D L. N U T T A L L : ~47 Taylor Street, Needham MA 02194, U.S.A. and "Department of Counseling and Developmental Research Methods, Boston College, Chestnut Hill, MA 02167, U.S.A. Abstract--The purpose of this study was to examine health related attitudes, including willingness to provide care, of health care professionals toward HIV-infected patients. To control for attitudes toward people who may have engaged in high risk behaviors for HIV infection, such as intravenous drug use or homosexual behavior, attitudes of pediatric nurses were studied since children with HIV almost never acquire the infection through these behaviors.The research population consisted of 517 pediatric nurses (46% response rate) from twenty states, the District of Columbia and Puerto Rico. The major findings were that those pediatric nurses with more experience caring for HIV-infected patients were more willing to care for these patients, and respondents reported more favorable attitudes after caring for people infected with HIV. Very few nurses would refuse to care for these children, although most acknowledged moderate fear of acquiring HIV from their patients. The level of experience caring for people with HIV was uncorrelated with reported likelihood of incidents of occupational HIV exposure risk. Greater occupational exposure risk was associated with less positive attitudes and less willingness to provide care. Implications of this study include that attitudes, including willingness to provide care, are more favorable with less suspected risk of infection and after more experience with such patients. In this study, where the sample of clients was adjusted to remove other biases, health caregivers were generally positive ronsard caring for HIV-infected patients. K e y words
AIDS, attitudes, pediatric, nurses
In this study we sought to explicate the relationships among health caregivers' sense of personal risk in caring for HIV-infected clients and both their willingness to provide health care under such circumstances and their attitudes toward these clients. We focused our research on attitudes of health caregivers toward people infected with HIV because of the growing prevalence of human immunodeficiency virus (HIV) infection, the possibility of becoming infected with HIV through occupational transmission, and the poor prognosis of those infected. The study examined attitudes in relation to two possible aspects of risk: (1) the extent of experience in the care of HIV-infected patients; and (2) reported exposure to actual patient care incidents where transmission of HIV might occur. With the increasing incidence of Acquired Immune Deficiency Syndrome (AIDS), there is growing concern that fear of becoming infected with HIV, and the consequent development of A I D S and eventual death, will affect the willingness of health caregivers to provide necessary care to these patients [1-5]. Dworkin, Albrecht, and Cooksey [6] found worry about treating people with A I D S was positively correlated with more invasive patient contact. Physicians and dentists have reported concern about contagion by HIV-infected patients [7, 8], and in one study of primary care physicians 50% said they would, if given the choice, refuse to care for such patients [9]. Others have reported substantial proportions of
nurses who thought they should have the right to refuse or who would, if given the choice, refuse [1, 10, 11]. Also, physicians have been found to be less willing to interact with A I D S than with leukemia patients [12]. It is fair to say that any health care worker could be concerned about the risks involved in caring for HIV-infected patients. In this study, in order to measure attitudes of health caregivers who have demonstrated concern over caring for HIV-infected patients and who have extensive physical contact with clients, and thus potential for occupational transmission of infection, we chose to study nurses. When Dworkin, Albrecht and Cooksey compared physicians, nurses and social workers in their responses to people with AIDS, nurses were found to express the most worry and discomfort with HIV patient care [6]. Nurses are the caregivers who are considered to be at the forefront of A I D S patient care [2, 6, 13, 14]. In many studies of caregivers' attitudes toward people with HIV infection, the relationship between attitudes and personal risk may have been clouded by negative attitudes toward groups of individuals disproportionally represented in those so infected, namely i.v. drug users, homosexual or bisexual men, or other individuals whose behaviors might have contributed to their acquiring the infection [3,4,15-17]. To present a clearer relationship between personal risk and attitudes, we studied caregiver attitudes toward HIV-infected children. 463
464
Research Note
Children with HIV infection are often identified as innocent victims [18, 19]. The vast majority of HIV-infected children acquire their disease simply by being born to an infected mother. Approximately 89% of pediatric acquired immunodeficiency syndrome (AIDS) infection, defined as infection in children under the age of 13, is transmitted perinatally [20]. Personal risk is considered in this study to have two major facets: experience and exposure. Experience in the care of HIV-infected patients refers to cumulative day-to-day contact with infected individuals through providing care. Occupational exposure, on the other hand, refers to specific incidents where transmission of HIV is possible. Customary care of all patients strives to avoid exposure incidents through the application of 'universal precautions,' e.g. wearing latex gloves when handling blood or body fluids. Incidents of occupational exposure, e.g. a contaminated needle penetrating a staff member's skin or a patient's bodily fluid or blood splashing a health care worker's broken skin or mucous membranes, can occur with a difficulty in or failure to apply universal precautions. In studies of attitudes toward people with HIV, relationships between attitudes, including willingness to provide care, and experience in the care of these patients have not been conclusive. Negative feelings about providing care for these patients can be high [12, 14]: Ruane and Conlon [21] found 80% of medical staff nurses surveyed would rather AIDS patients were admitted to another unit. However both Bond et al. and Ficarrotto et al. found greater prior experience with HIV-infected patients was associated with less resistance to providing care [10, 15]: Storosum et al. found physicians and nurses in areas of lowest HIV incidence were more adverse to caring for HIVinfected patients [7]. Gerbert et al. reported a complicated relationship between experience and attitudes. In Gerbert et al.'s study, physicians' experience was unrelated to their expressed responsibility for treating AIDS patients and concurrent desire to refuse to treat them if given a choice. Willingness to treat, however, seemed related to greater experience [9]. Kemppainen et al. on the other hand, reported a different relationship between experience and willingness to provide care [2]. Nurses employed in hospitals with high proportions of HIV-infected patients were less willing to perform 13 specific nursing procedures than were nurses working in hospitals with low or moderate incidence of HIV-infected patients. Nurses in these high HIV incidence hospitals tended to be more experienced in caring for this patient population. Others researchers have found no significant relationship between the level of experience caring for HIV-infected patients and attitudes concerning providing care [3, 4, 16]. Although the relationships between experience and attitudes have been found to differ between studies, the relationships of attitudes and exposure to
actual or perceived infection risks have been more uniform. A significant relationship has been demonstrated between perceived risk of becoming infected and both negative attitudes and less willingness to provide care to HIV-infected patients [13, 15,22]. Dworkin et al. found that nurses more worried about spreading HIV to their families were significantly less willing to work on an AIDS unit [6]. In addition, nurses' fears of occupational transmission of HIV sometimes have been prevalent despite limited or no experience [11] and both excessive and far out of proportion to estimated infection risks [13]. We hypothesized that nurses with higher reported occupational exposure risk would have less positive attitudes toward caring for HIV-infected patients. Experience caring for HIV-infected patients does not necessarily involve infection risk incidents. We expected reported exposure to HIV infection risk to have, in fact, little relationship to level of experience caring for HIV-infected patients. Unlike those nurses with higher reported occupational exposure, we hypothesized nurses with higher levels of experience caring for HIV-infected patients would be more positive in their attitudes towards such patients. We expected more experienced nurses to be more informed about and less fearful of HIV infection risks, and more willing to care for people infected with HIV. This hypothesis was consistent with Ficarrotto et al. [15], although it was contrary to the findings of Kemppainen et al. [2]. More favorable attitudes were expected with more experienced nurses because (1) some would self-select to work with HIV-infected children and also because (2) nurses finding themselves working with this population would need to deal with any negative attitudes or concerns for potential personal risks, so as to remain in their jobs. Cognitive dissonance theory postulates that when people are in a situation where their behavior and attitudes are in conflict, they tend either to develop attitudes supportive of their behavior or to extricate themselves from the conflict-ridden situation [23]. Since this study focused on attitudes toward those who could not be said to bear responsibility for their infection, we did not expect a merely neutral, or nonsignificant, relationship between experience and favorable attitudes reported in some studies [3, 4, 16]. METHODOLOGY
The survey instrument
The survey, sponsored by the authors, was conducted in the spring of 1992. The instrument in its entirety can be found in Berkowitz [24]. The sample
We chose our sample so as to guarantee nurses with varying levels of experience with HIV-infected
Research Note children were included. The sampling unit for both sources was the individual nurse. First, we sought pediatric nurses who might have some, but not extensive, experience by a random selection of nurses from three state nurses' associations. Half of the enrolled pediatric nurses from metropolitan New York and Boston and urban Chicago were randomly selected to receive the survey instrument. Secondly, in order to survey attitudes of nurses with extensive experience caring for HIV-infected children, the survey was mailed to coordinators or nurse administrators of organizations known to provide nursing care for HIV-infected children. Questionnaires were sent to coordinators of all pediatric AIDS clinical trial units (ACTUs), to federally funded pediatric AIDS demonstration projects where nurses provided direct patient care, and to a nurse administrator of the pediatric units of a Boston hospital providing care for numerous HIV-infected children. Analysis showed the samples did not differ significantly by age, education level, length of time worked either as a nurse or specifically with children, or reported level of occupational exposure risk. The total number of questionnaires distributed (1140) was reduced to 1131 because of non-current addresses or because respondents either were not pediatric nurses or were retired. Five hundred and seventeen usable questionnaires were received from 20 states, the District of Columbia, and Puerto Rico, for an overall response rate of 46%.
Experience scale dUTnition Five items comprised the experience scale: 1. the number of HIV-infected patients with whom the nurse had direct contact; 2. the number of HIV-infected patients for whom the nurse had done primary care; 3. the proportion of the nurse's practice that was HIV-infected; 4. the number of years caring for HIV-infected patients; and 5. the number of years caring for HIV-infected children. The experience measure was the mean of the five items. The experience scale had a Cronbach ~ reliability of 0.84.
Measure qf e.xposure risk Questions about exposure risk incidents were asked separately from items about experience caring for people infected with HIV. To ensure that relationships concerning exposure were based on occupational risk rather than HIV exposure risk in personal life, the likelihood of respondents' exposure to HIV in both personal life and from work-related sources was asked. Questions about occupational exposures, such as contact with infected body fluids and blood products or contaminated needle sticks, formed a scale considered to have very good reliability (Cronbach = 0.81) [26].
465
Attitude .factors Principal factor axis analysis followed by varimax rotation yielded four professional health care attitude factors according to Cattell's scree procedure [25]. These were: 1. +willingness-to-care' for an HIV-infected child; 2. +fear" of acquiring HIV infection from providing care; 3. +futility' of providing care for these children and their families; and 4. 'distress' of caring for a child who is likely to die and to whom one has become emotionally attached. The Appendix contains Cronbach :~ coefficients and the items for each professional health care attitude factor. Attitude factors were scored on a 1-7 scale, with 1 = strongly disagree; 2 = disagree; 3 = slightly disagree: 4 = neutral (respondent-added response): 5 = slightly agree: 6 = agree; and 7 = strongly agree to items favoring the attitude object. Thus any mean score above 4.0 indicated a tendency to agree and any score mean below 4.0 indicated a tendency to disagree.
RESULTS The overwhelming majority of nurses in this study said they would care for an HIV-infected child. Over 75% felt a nurse does not have the right to refuse to care for an HIV-infected patient, although almost 9% said they would refuse to care for an HIV-infected child if given the choice. Only 1.4% said they would refuse outright to provide such care. Despite a willingness and an expressed responsibility to care for children infected with HIV, two-thirds of these nurses said their family and friends were concerned about them caring for HIV-infected patients. These concerns did not exist in a vacuum, as most pediatric nurses in this sample had significant experience with HIV-infected patients. Seventy-one percent reported a patient in their clinical practice had died of an HIV-related cause. The mean responses of pediatric nurses to the four health care related attitudes are presented in the Appendix. For the whole sample, pediatric nurses tended to agree with the 'willingness-to-care" factor (M = 5.88), and slightly agree with the +fear" factor ( M = 4 . 4 6 ) , and the +distress' factor ( M = 4 . 1 9 ) . However they tended to disagree with the "futility' factor (M = 2.37). To determine whether nurses' attitudes toward HIV-infected people predated or were the result of experience in HIV nursing care, we asked nurses if their attitudes had changed after caring for these patients. While 40% of respondents reported no change in attitudes after caring for people with HIV, over 57% stated their feelings became more positive after experience with infected patients: < 3% reported
Research Note
466
Table 1. Correlations of occupational exposure vs personal exposure risk with professional health care attitude factors Felt exposed to Felt exposed to HIV Health attitude factor HIV on job in personal life Willingness to care -0.19"** Futility 0.14"** Fear 0.34*** Distress 0.08 Note: *** means significant at <0.001 level
0.03 0.04 0.06 0.03
more negative attitudes [24]. Thus pediatric nurses' experience with people infected with H I V usually engendered more positive attitudes and rarely more negative ones.
Reported exposure to HIV infection risk and health care attitudes In this sample 50% felt it was at least somewhat likely they had been occupationally exposed to HIV. However only 14% reported that level o f exposure in their personal lives. Level of occupational exposure to HIV. W h e n asked which of five risk likelihood categories best described their level of occupational exposure to the A I D S virus on-the-job, some 18% felt that such exposure was highly p r o b a b l e and a n o t h e r 32% felt that such exposure was slightly probable. H a l f felt that it was unlikely (18%), very unlikely (20%) or not at all possible (12%) for them to have been exposed to the H I V virus on-the-job. Level of exposure to HIV m personal I!/b. In terms of exposure to A I D S in their personal life, only t w o % felt that such exposure was highly p r o b a b l e and an additional 12% felt that it was slightly probable. Some 86% felt that such private life exposure was unlikely, very unlikely, or not at all possible.
Comparison of occupational and personal l!)re exposure to H1V risk. T a k e n together, HIV exposure risk data suggest the majority of nurses who reported feeling exposed to a risk of H I V infection identified the exposure as occupational rather t h a n in personal life. F o r those nurses reporting at least a slightly p r o b a b l e exposure to HIV, 78% reported it was t h r o u g h occupational exposure. O f those reporting a high probability of exposure, 90% felt the risk occurred in the occupational setting.
Source of HIV exposure risk and health care attitudes. The correlations between all four health care attitude factors and exposure in personal life was almost zero (r = 0.03 to r = 0.06). Exposure risk in personal life was then dropped from further data analyses. The relationships of reported exposure a n d health care attitudes are summarized in Table 1. Felt exposure to H I V infection risk on-the-job was significantly related to three of the four professional health attitude factors. Nurses who reported greater occupational exposure to H I V infection risk were less likely to be willing to care for HIV-infected children (r = - 0.19), and they were more likely to express fear of acquiring the infection from their patients (r = 0.34) a n d to feel that such care was futile ( r = 0 . 1 4 ) . Occupational exposure, then, was included in regression analyses of the health care attitude factors.
Relationship of attitudes to experience, exposure and other independent variables Using stepwise regression, eight i n d e p e n d e n t variables were regressed on the four health care attitude factors. I n d e p e n d e n t variables included experience caring for HIV-infected patients, reported occupational exposure, highest educational level achieved, length of time worked as a nurse, age, gender, religiosity and sexual orientation. Variables were stepped in if they were adding statistically significant (ct < 0.05) variance and added at least o n e % to the explained variance (R2). Experience and occupational exposure explained significant variability on the three health care attitude factors that h a d respectable reliability: 'willingness to care', 'fear' and 'futility' (see Table 2). O f the 24% explained variance on 'willingness to care' experience accounted for 19% with occupational exposure relating negatively to willingness-to-care and explaining an additional 5%. Regarding the 'fear' factor, nurses reporting occupational exposure were not only less willing to provide care, as noted above, but also were more fearful of infection, with occupational exposure explaining 10% of variance on the fear factor. Educational level of the nurse was significantly related to the fear factor. Education level and experience were b o t h negatively related to fear and
Table 2. Regression of independent variables on health care attitude factors Independent variables /3 R2 change Significance Willingness to care R~,~j= 0.24 F,2.47~= 7 6 . 5 4 Significance<0.0001 Experience 0.45 0.19 < 0.0001 Occupational exposure - 0.22 0.05 < 0.0001
Fear
RAdj= 0. I7 0.30 - 0.20 - 0.15
F~,75~= 3 3 . 2 5 0.10 0.05 0.02
Significance< 0.0001 _<0.0001 < 0.0001 < 0.0005
Experience Occupational exposure
R~dj= 0.05 - 0.18 0.15
F~,4;5~= 1 2 . 7 2 0.03 0.02
Significance_<0.0001 < 0.0001 < 0.0012
Distress
R~dj =
0.02 0.15
F,.,77~= 10.33 0.02
Significance~0.0014 < 0.0014
Occupational exposure Education level Experience
Futilio'
Age of nurse
Research Note together accounted for another 7% of variance. For 'futility,' experience (negatively related) and occupational exposure (positively related) together explained approx. 5% of variance. The only variable entering the regression equation for the 'distress' factor was the nurse's age, with older nurses expressing more distress. Other independent variables either did not enter into the regression equations or explained < 1% of the variability. As we expected, experience caring for HIV-infected children was not necessarily synonymous with reported risk of acquiring HIV infection on-the-job. In fact, the correlation between experience and reported exposure risk was nonsignificant and almost zero (r = 0.04). Whereas more experience was positively correlated with 'willingness-to-care' and negatively correlated with "fear' and 'futility', higher reported risk of occupational exposure was correlated in opposite directions with these attitudes. Nurses who reported higher risk of exposure to HIV infection were significantly more likely to feel fear and to feel care for HIV-infected children was futile and were less willing to provide care.
DISCUSSION In this study we sought to assess attitudes of caregivers toward HIV-infected patients while controlling for attitudes toward people engaging in high risk behaviors. We chose to study pediatric nurses caring for H IV-infected children because nurses are in the front lines of HIV care and HIV-infected children are often regarded as innocent victims. Moreover the risk of occupational infection is potentially great with this population. We looked at risks as composed of two factors, experience and exposure, and formulated two hypotheses. The first hypothesis was that pediatric nurses with more experience in caring for HIV-infected children would have more posith,e attitudes toward caring for such patients. The second was that nurses who felt they had greater occupationalexposure to risks of HIV infection, such as exposure to blood and body fluids or needle sticks, would have less favorable attitudes. Factor analysis resolved the health attitude items into four factors, and both hypotheses were upheld for three of the four factors: 'willingnessto care', 'fear' and 'futility'. The fourth factor, 'distress', was not significantly related to either experience with HIVinfected patients or occupational exposure. The correlation between the experience and exposure measures was not significant, and was in fact almost zero. Supporting the findings of Ficarrotto et al. [15] that greater experience related to less resistance toward providing care, pediatric nurses in this study who were heavily involved in serving HIV-infected patients generally had more positive and less fearful attitudes toward these patients than did nurses with less experience. The relationship between attitudes and
467
experience in this study are in contrast with reports of no significant relationship between experience and attitudes [3, 4, 16], and to a negative relationship reported by Kemppainen et al. [2]. There were several differences between our study and Kemppainen et al. including the method of measuring both experience and willingness to care. Possibly most importantly, our respondents were pediatric nurses caring tbr children while Kemppainen et al.'s respondents were employed in Veterans Administration hospitals and presumably cared for an adult population. We must note, however, that even the nurses in our study with little or no experience with HIV-infected patients did not have negative attitudes toward such patients. For the most part they did not feel that it was futile to expend medical resources on HIV-infected children, nor did these nurses feel that treating these patients was excessively distressing. In particular, very few of the nurses (1.4%) were unwilling to care for these patients. When asked if they would refuse to care for an HIV-infected child, if given the choice, only 9% of pediatric nurses in this study said they would refuse. However, 50% of primary care physicians [9], and between 45 and 65% of critical care nurses [1] would refuse to care for AIDS patients if given the choice. Bond et al. reported 26% of community nurses in England [10] and Koch et al. found 23% of rural nurses in the northeastern U.S. [4] felt they should have the right to refuse care for people with AIDS, while Campbell et al. reported 55% of hospital nurses had these feelings [11]. Our findings are more compatible with Bond et al. and Koch et al.. as 75% of our respondents felt a nurse does not have the right to refuse to care for HIV-infected children. At least in our study, where HIV-infected individuals did not have behaviors which could have led to their infections, nurses have positive attitudes toward them and are committed to their care. Those nurses who suspected they had been occupationally exposed to HIV, however, generally had more negative attitudes towards and were more likely to refuse to care for people with HIV. Our results support other researchers who have found a negative relationship between suspected HIV risk and favorable attitudes such as willingness to provide care [13, 15, 22]. In our study nurses, regardless of experience level, had a slight tendency to agree with the "fear" of occupational exposure items; but not present in this population were high levels of fear reported elsewhere [13]. Thus, while pediatric nurses in this sample can be said to have generally positive attitudes toward HIV-positive patients, they also tend to have a healthy respect for the dangers of infection and for the risks of contracting this disease. While aware of and concerned with personal risk, pediatric nurses are not seriously affected by such fears in their professional lives, In summary we found that pediatric nurses who had more experience with HIV-infected children were less
468
Research Note
afraid a n d h a d m o r e positive attitudes t o w a r d these p a t i e n t s t h a n did t h o s e nurses with less experience. T h e s e positive attitudes were reflected in a g r e a t e r willingness to care a n d a d e c r e a s e d sense o f futility in w o r k i n g with H I V - i n f e c t e d children. M o r e o v e r , m o r e t h a n h a l f the nurses in this s a m p l e r e p o r t e d that increased e x p e r i e n c e e n g e n d e r e d m o r e positive attitudes t o w a r d p e o p l e infected with H I V . While they did have realistic fears o f infection, there was n o i n d i c a t i o n that these nurses, regardless o f level o f experience, were unwilling to care for H I V - i n f e c t e d patients. W e c o n c l u d e d that w h e n the s a m p l e o f clients is a d j u s t e d to r e m o v e o t h e r biases, risk o f acquiring a fatal infection is n o t sufficient to dissuade caregivers f r o m either their positive attitudes t o w a r d p a t i e n t s o r willingness to care for them. Only f u r t h e r research will s h o w w h e t h e r these results m a y be generalizable to o t h e r p o p u l a t i o n s o f caregivers o r to o t h e r g r o u p s o f p a t i e n t s p o t e n t i a l l y h a z a r d o u s to the caregiver. REFERENCES
1. Damrosch S., Abbey S., Warner A. and Guy S. Critical care nurses' attitudes toward, concerns about, and knowledge of the acquired immunodeFIciency syndrome. Heart Lung: J. Critical Care 19, 395, 1990. 2. Kemppainen J., St. Lawrence J. S., Irizarry A., Weidema D. R., Benne C., Fredericks C. D. and Wilson M. Nurses' willingness to perform AIDS patient care. J. Continuing Educ. Nursing 23, 110, 1992. 3. Klonoff E. A. and Ewers D. Care of AIDS patients as a source of stress to nursing staff. A I D S Educ. Prevention 2, 338, 1990. 4. Koch P. B., Preston D. B., Young E. W. and Wang M. Factors associated with AIDS-related attitudes among rural nurses. Hlth Values 15, (6) 32, 1991. 5. van Servellen G., Lewis C. E. and Leake B. The limitations of generic AIDS education programs for the health professions. J. Continuing Educ. Hlth Professions 10, 223 236, 1990. 6. Dworkin J., Albrecht G. and Cooksey J. Concern about AIDS among hospital physicians, nurses, and social workers. Soc. Sci. Med. 33, 239, 1991. 7. Storosum J. G., Sno H. N., Schalken H. F. A., Krol L. J., Swinkels J. A., Nahuijs M., Meijer E. P. and Danner S. A. Attitudes of health-care workers towards AIDS at three Dutch hospitals. A I D S 5, 55, 1991. 8. Kunzel C. and Sadowsky D. Predicting dentists" perceived occupational risk for HIV infection. Soc. Sci. Med. 12, 1579, 1993. 9. Gerbert B., Maguire B. T., Bleecker T., Coates T. J. and McPhee S. J. Primary care physicians and AIDS. J. Am. Med. Assoc. 266, 2837, 1991. 10. Bond S., Rhodes T., Philips P., Setters J., Foy C. and Bond J. HIV infection and AIDS in England: the experience, knowledge, and intentions of community nursing staff. J. Adv. Nursing 15, 249, 1990. 11. Campbell S., Maki M., Willenbring K. and Henry K. AIDS-related knowledge, attitudes, and behaviors among 629 registered nurses at a Minnesota hospital: a descriptive study. J. Assoc. Nurses A I D S Care: J A N A C 2, 15, 1991. 12. Kelly J. A., St. Lawrence J. S., Smith S., Hood H. V. and Cook D. J. Stigmatization of AIDS patients by physicians. Am. J. Publ. Hlth 77, 789, 1987. 13. Ficarrotto T. J., Grade M. and Zegans L. S. Occupational and personal risk estimates for HIV contagion among incoming graduate nursing students. J. Assoc. Nurses A I D S Care: J A N A C 2, 5, 1991.
14. Kelly J. A., St. Lawrence J. S., Hood H. V., Smith S. and Cook D. J. Nurses' attitudes toward AIDS. J. Continuing Educ. Nursing 19, (2) 78, 1988. 15. Ficarrotto T. J., Grade M., Bliwise N. and Irish T. Predictors of medical and nursing students' levels of HIV-AIDS knowledge and their resistance to working with AIDS patients. Acad+ Med. 65, 470, 1990. 16. Forrester D. A. and Murphy P. A. Nurses" attitudes toward patients with AIDS and AIDS-related risk factors. J. Adv. Nursing 17, 1260, 1992. 17. Meisenhelder J. B. Contributing factors to fear of HIV contagion in registered nurses. IMAGE: J. Nursing Scholarship 26, 65, 1994. 18. Denker A. L. Nursing care of children with acquired immunodeficiency Syndrome: A grounded theory approach. Unpublished Doctoral Dissertation, University of Miami, Coral Gables, FL, 1989. 19. Novick A. What are the responsibilities of HIV-infected persons? What are the reciprocal responsibilities of society? A I D S Publ. Policy J. 9, 55, 1994. 20. H I V / A 1 D S Surveillance Report, Year End Edition, Vol. 5. Centers for Disease Control and Prevention, Atlanta, GA: U.S. Dept. of Health and Human Services, 5(4), 1994. 21. Ruane B. A. and Conlon M. Recruitment and retention strategies tot an AIDS unit. Recruitment Retention Rep. 5, (9) 1, 1992. 22. Jemmott J. B. 1., Freleicher J. and Jemmott L. S. Perceived risk of infection and attitudes toward risk groups: determinants of nurses' behavioral intentions regarding AIDS patients. Res. Nursing Hlth 15, 295, 1992. 23. Festinger L. ,4 Theo O, ~1 Cognitive Dissonance. Row-Peterson, Evanston, IL, t957. 24. Berkowitz N. F. Nurses' attitudes toward caring for HIV-infected children. 1993. Unpublished Doctoral Dissertation, Boston College, Chestnut Hill, MA. 25. Cattell R. B. The scree test for the number of factors. Multh,ariate Behat,. Res. 1,245+ 1966. 26. DeVellis R. F. Scale development theory and applications. Applied Social Research Methods Series (Edited by Bickman L. and Rog D. J.), Vol. 26. Sage Publications, Newbury Park, 1991.
APPENDIX H e a l t h care attitude J a c t o r s i. Willingness to care, ~ = 0.84, mean = 5.88, SD = 0.6
If given the choice, Fd refuse to care for an HIV-infected child. (reversed) 1 would have to overcome a lot of my own resistance to care for an HIV-infected child. (reversed) I can't bear caring for HIV-infected babies. (reversed) I try not to touch my HIV-infected patients. (reversed) I interact with HIV-infected patients as much as I interact with my other patients. I would provide care for an HIV-infected child. I would find caring for an HIV-infected child deeply satisfying. I can't imagine a child I'd less like to care for than an HIV-infected child. (reversed) I just cannot let myself get attached to an H1V-infected child. (reversed) I feel well enough informed about HIV infection to care for these patients. No one really knows how "at risk" nurses or physicians are to get AIDS from HIV-infected patients. (reversed) I don't think I can stand to see another HIV-infected child. (reversed) A nurse has the right to refuse to care for an HIV-infected patient. (reversed)
Research Note 1 feel confident that adhering to infection control guidelines and precautions will protect me from contracting HIV. A physician has the right to refuse to care for an H1V-infected patient. (reversed) 2.
F e a r , ~: = O. 74, m e a n
= 4.46, SD
= 1.2
It's hard to take care of any infant without worrying about getting infected with HIV. I often think of myself as 'at risk' for HIV. 1 just don't worry about getting HIV from my patients. (reversed) tt IV has caused nursing to become a 'high risk' occupation. I rarely think of HIV exposure at my workplace. (reversed) In my specialty, there's little risk of exposure to HIV. (reversed) Every time I see a newborn baby I think "this baby might be HlV-infected." 3.
Futility,
~ = O. 75, m e a n
:= 2 , 3 7 ,
SD = 2.2
There's not much point in pouring out precious medical resources for HIV-infected children. Families with HIV infection are n o t capable of complying with health care routines, Families with HIV-infected children don't want the health care 1 have to offer. Morns of HIV-infected infants don't pay much attention to medical follow-up for their babies.
SSM 42/3--L,
469
Parents of HIV-infected children are likely to be on drugs, the streets or dead. Parents of HIV-infected children are too psychologically fragile, The last thing I want is for a drug-using HIV-infected mother to tell me how to care for her child. I don't enjoy working with low-income minority families. There's n o t much we can do to decrease the spread of HIV in drug abusing women. Abortion is the best option for a pregnant HIV-infected woman. 4. D i s t r e s s ,
~ = 0.62, mean
= 4 . 1 9 , S D = 1.0
I feel overwhelmed when both a mother and her child have a fatal disease. Working with H1V-infected children is tense--like waiting for the other shoe to drop. 1 can't stand wondering whether or not an HIV positive baby is really HIV-infected. People don't understand how much harder it is to care for a mother or her child when both are dying of HIV infection. Caring for HIV-infected children means you're up to your eyeballs with work. I always want to help the underdog. I don't think of 'if' HIV-infected children will die but "when' they will die. I wish l could be the one to make care decisions for HlV-infected children.
Pergamon
Vol. 42, No. 3, pp. 463-469. 1996 Copyright © 1996 ElsevierScienceLtd Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00
Soc. Sci. Med.
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RESEARCH NOTE A T T I T U D E S OF P E D I A T R I C N U R S E S F A C I N G HIV RISK N A N C Y F. B E R K O W I T Z ~ and R O N A L D L. N U T T A L L : ~47 Taylor Street, Needham MA 02194, U.S.A. and "Department of Counseling and Developmental Research Methods, Boston College, Chestnut Hill, MA 02167, U.S.A. Abstract--The purpose of this study was to examine health related attitudes, including willingness to provide care, of health care professionals toward HIV-infected patients. To control for attitudes toward people who may have engaged in high risk behaviors for HIV infection, such as intravenous drug use or homosexual behavior, attitudes of pediatric nurses were studied since children with HIV almost never acquire the infection through these behaviors.The research population consisted of 517 pediatric nurses (46% response rate) from twenty states, the District of Columbia and Puerto Rico. The major findings were that those pediatric nurses with more experience caring for HIV-infected patients were more willing to care for these patients, and respondents reported more favorable attitudes after caring for people infected with HIV. Very few nurses would refuse to care for these children, although most acknowledged moderate fear of acquiring HIV from their patients. The level of experience caring for people with HIV was uncorrelated with reported likelihood of incidents of occupational HIV exposure risk. Greater occupational exposure risk was associated with less positive attitudes and less willingness to provide care. Implications of this study include that attitudes, including willingness to provide care, are more favorable with less suspected risk of infection and after more experience with such patients. In this study, where the sample of clients was adjusted to remove other biases, health caregivers were generally positive ronsard caring for HIV-infected patients. K e y words
AIDS, attitudes, pediatric, nurses
In this study we sought to explicate the relationships among health caregivers' sense of personal risk in caring for HIV-infected clients and both their willingness to provide health care under such circumstances and their attitudes toward these clients. We focused our research on attitudes of health caregivers toward people infected with HIV because of the growing prevalence of human immunodeficiency virus (HIV) infection, the possibility of becoming infected with HIV through occupational transmission, and the poor prognosis of those infected. The study examined attitudes in relation to two possible aspects of risk: (1) the extent of experience in the care of HIV-infected patients; and (2) reported exposure to actual patient care incidents where transmission of HIV might occur. With the increasing incidence of Acquired Immune Deficiency Syndrome (AIDS), there is growing concern that fear of becoming infected with HIV, and the consequent development of A I D S and eventual death, will affect the willingness of health caregivers to provide necessary care to these patients [1-5]. Dworkin, Albrecht, and Cooksey [6] found worry about treating people with A I D S was positively correlated with more invasive patient contact. Physicians and dentists have reported concern about contagion by HIV-infected patients [7, 8], and in one study of primary care physicians 50% said they would, if given the choice, refuse to care for such patients [9]. Others have reported substantial proportions of
nurses who thought they should have the right to refuse or who would, if given the choice, refuse [1, 10, 11]. Also, physicians have been found to be less willing to interact with A I D S than with leukemia patients [12]. It is fair to say that any health care worker could be concerned about the risks involved in caring for HIV-infected patients. In this study, in order to measure attitudes of health caregivers who have demonstrated concern over caring for HIV-infected patients and who have extensive physical contact with clients, and thus potential for occupational transmission of infection, we chose to study nurses. When Dworkin, Albrecht and Cooksey compared physicians, nurses and social workers in their responses to people with AIDS, nurses were found to express the most worry and discomfort with HIV patient care [6]. Nurses are the caregivers who are considered to be at the forefront of A I D S patient care [2, 6, 13, 14]. In many studies of caregivers' attitudes toward people with HIV infection, the relationship between attitudes and personal risk may have been clouded by negative attitudes toward groups of individuals disproportionally represented in those so infected, namely i.v. drug users, homosexual or bisexual men, or other individuals whose behaviors might have contributed to their acquiring the infection [3,4,15-17]. To present a clearer relationship between personal risk and attitudes, we studied caregiver attitudes toward HIV-infected children. 463
464
Research Note
Children with HIV infection are often identified as innocent victims [18, 19]. The vast majority of HIV-infected children acquire their disease simply by being born to an infected mother. Approximately 89% of pediatric acquired immunodeficiency syndrome (AIDS) infection, defined as infection in children under the age of 13, is transmitted perinatally [20]. Personal risk is considered in this study to have two major facets: experience and exposure. Experience in the care of HIV-infected patients refers to cumulative day-to-day contact with infected individuals through providing care. Occupational exposure, on the other hand, refers to specific incidents where transmission of HIV is possible. Customary care of all patients strives to avoid exposure incidents through the application of 'universal precautions,' e.g. wearing latex gloves when handling blood or body fluids. Incidents of occupational exposure, e.g. a contaminated needle penetrating a staff member's skin or a patient's bodily fluid or blood splashing a health care worker's broken skin or mucous membranes, can occur with a difficulty in or failure to apply universal precautions. In studies of attitudes toward people with HIV, relationships between attitudes, including willingness to provide care, and experience in the care of these patients have not been conclusive. Negative feelings about providing care for these patients can be high [12, 14]: Ruane and Conlon [21] found 80% of medical staff nurses surveyed would rather AIDS patients were admitted to another unit. However both Bond et al. and Ficarrotto et al. found greater prior experience with HIV-infected patients was associated with less resistance to providing care [10, 15]: Storosum et al. found physicians and nurses in areas of lowest HIV incidence were more adverse to caring for HIVinfected patients [7]. Gerbert et al. reported a complicated relationship between experience and attitudes. In Gerbert et al.'s study, physicians' experience was unrelated to their expressed responsibility for treating AIDS patients and concurrent desire to refuse to treat them if given a choice. Willingness to treat, however, seemed related to greater experience [9]. Kemppainen et al. on the other hand, reported a different relationship between experience and willingness to provide care [2]. Nurses employed in hospitals with high proportions of HIV-infected patients were less willing to perform 13 specific nursing procedures than were nurses working in hospitals with low or moderate incidence of HIV-infected patients. Nurses in these high HIV incidence hospitals tended to be more experienced in caring for this patient population. Others researchers have found no significant relationship between the level of experience caring for HIV-infected patients and attitudes concerning providing care [3, 4, 16]. Although the relationships between experience and attitudes have been found to differ between studies, the relationships of attitudes and exposure to
actual or perceived infection risks have been more uniform. A significant relationship has been demonstrated between perceived risk of becoming infected and both negative attitudes and less willingness to provide care to HIV-infected patients [13, 15,22]. Dworkin et al. found that nurses more worried about spreading HIV to their families were significantly less willing to work on an AIDS unit [6]. In addition, nurses' fears of occupational transmission of HIV sometimes have been prevalent despite limited or no experience [11] and both excessive and far out of proportion to estimated infection risks [13]. We hypothesized that nurses with higher reported occupational exposure risk would have less positive attitudes toward caring for HIV-infected patients. Experience caring for HIV-infected patients does not necessarily involve infection risk incidents. We expected reported exposure to HIV infection risk to have, in fact, little relationship to level of experience caring for HIV-infected patients. Unlike those nurses with higher reported occupational exposure, we hypothesized nurses with higher levels of experience caring for HIV-infected patients would be more positive in their attitudes towards such patients. We expected more experienced nurses to be more informed about and less fearful of HIV infection risks, and more willing to care for people infected with HIV. This hypothesis was consistent with Ficarrotto et al. [15], although it was contrary to the findings of Kemppainen et al. [2]. More favorable attitudes were expected with more experienced nurses because (1) some would self-select to work with HIV-infected children and also because (2) nurses finding themselves working with this population would need to deal with any negative attitudes or concerns for potential personal risks, so as to remain in their jobs. Cognitive dissonance theory postulates that when people are in a situation where their behavior and attitudes are in conflict, they tend either to develop attitudes supportive of their behavior or to extricate themselves from the conflict-ridden situation [23]. Since this study focused on attitudes toward those who could not be said to bear responsibility for their infection, we did not expect a merely neutral, or nonsignificant, relationship between experience and favorable attitudes reported in some studies [3, 4, 16]. METHODOLOGY
The survey instrument
The survey, sponsored by the authors, was conducted in the spring of 1992. The instrument in its entirety can be found in Berkowitz [24]. The sample
We chose our sample so as to guarantee nurses with varying levels of experience with HIV-infected
Research Note children were included. The sampling unit for both sources was the individual nurse. First, we sought pediatric nurses who might have some, but not extensive, experience by a random selection of nurses from three state nurses' associations. Half of the enrolled pediatric nurses from metropolitan New York and Boston and urban Chicago were randomly selected to receive the survey instrument. Secondly, in order to survey attitudes of nurses with extensive experience caring for HIV-infected children, the survey was mailed to coordinators or nurse administrators of organizations known to provide nursing care for HIV-infected children. Questionnaires were sent to coordinators of all pediatric AIDS clinical trial units (ACTUs), to federally funded pediatric AIDS demonstration projects where nurses provided direct patient care, and to a nurse administrator of the pediatric units of a Boston hospital providing care for numerous HIV-infected children. Analysis showed the samples did not differ significantly by age, education level, length of time worked either as a nurse or specifically with children, or reported level of occupational exposure risk. The total number of questionnaires distributed (1140) was reduced to 1131 because of non-current addresses or because respondents either were not pediatric nurses or were retired. Five hundred and seventeen usable questionnaires were received from 20 states, the District of Columbia, and Puerto Rico, for an overall response rate of 46%.
Experience scale dUTnition Five items comprised the experience scale: 1. the number of HIV-infected patients with whom the nurse had direct contact; 2. the number of HIV-infected patients for whom the nurse had done primary care; 3. the proportion of the nurse's practice that was HIV-infected; 4. the number of years caring for HIV-infected patients; and 5. the number of years caring for HIV-infected children. The experience measure was the mean of the five items. The experience scale had a Cronbach ~ reliability of 0.84.
Measure qf e.xposure risk Questions about exposure risk incidents were asked separately from items about experience caring for people infected with HIV. To ensure that relationships concerning exposure were based on occupational risk rather than HIV exposure risk in personal life, the likelihood of respondents' exposure to HIV in both personal life and from work-related sources was asked. Questions about occupational exposures, such as contact with infected body fluids and blood products or contaminated needle sticks, formed a scale considered to have very good reliability (Cronbach = 0.81) [26].
465
Attitude .factors Principal factor axis analysis followed by varimax rotation yielded four professional health care attitude factors according to Cattell's scree procedure [25]. These were: 1. +willingness-to-care' for an HIV-infected child; 2. +fear" of acquiring HIV infection from providing care; 3. +futility' of providing care for these children and their families; and 4. 'distress' of caring for a child who is likely to die and to whom one has become emotionally attached. The Appendix contains Cronbach :~ coefficients and the items for each professional health care attitude factor. Attitude factors were scored on a 1-7 scale, with 1 = strongly disagree; 2 = disagree; 3 = slightly disagree: 4 = neutral (respondent-added response): 5 = slightly agree: 6 = agree; and 7 = strongly agree to items favoring the attitude object. Thus any mean score above 4.0 indicated a tendency to agree and any score mean below 4.0 indicated a tendency to disagree.
RESULTS The overwhelming majority of nurses in this study said they would care for an HIV-infected child. Over 75% felt a nurse does not have the right to refuse to care for an HIV-infected patient, although almost 9% said they would refuse to care for an HIV-infected child if given the choice. Only 1.4% said they would refuse outright to provide such care. Despite a willingness and an expressed responsibility to care for children infected with HIV, two-thirds of these nurses said their family and friends were concerned about them caring for HIV-infected patients. These concerns did not exist in a vacuum, as most pediatric nurses in this sample had significant experience with HIV-infected patients. Seventy-one percent reported a patient in their clinical practice had died of an HIV-related cause. The mean responses of pediatric nurses to the four health care related attitudes are presented in the Appendix. For the whole sample, pediatric nurses tended to agree with the 'willingness-to-care" factor (M = 5.88), and slightly agree with the +fear" factor ( M = 4 . 4 6 ) , and the +distress' factor ( M = 4 . 1 9 ) . However they tended to disagree with the "futility' factor (M = 2.37). To determine whether nurses' attitudes toward HIV-infected people predated or were the result of experience in HIV nursing care, we asked nurses if their attitudes had changed after caring for these patients. While 40% of respondents reported no change in attitudes after caring for people with HIV, over 57% stated their feelings became more positive after experience with infected patients: < 3% reported
Research Note
466
Table 1. Correlations of occupational exposure vs personal exposure risk with professional health care attitude factors Felt exposed to Felt exposed to HIV Health attitude factor HIV on job in personal life Willingness to care -0.19"** Futility 0.14"** Fear 0.34*** Distress 0.08 Note: *** means significant at <0.001 level
0.03 0.04 0.06 0.03
more negative attitudes [24]. Thus pediatric nurses' experience with people infected with H I V usually engendered more positive attitudes and rarely more negative ones.
Reported exposure to HIV infection risk and health care attitudes In this sample 50% felt it was at least somewhat likely they had been occupationally exposed to HIV. However only 14% reported that level o f exposure in their personal lives. Level of occupational exposure to HIV. W h e n asked which of five risk likelihood categories best described their level of occupational exposure to the A I D S virus on-the-job, some 18% felt that such exposure was highly p r o b a b l e and a n o t h e r 32% felt that such exposure was slightly probable. H a l f felt that it was unlikely (18%), very unlikely (20%) or not at all possible (12%) for them to have been exposed to the H I V virus on-the-job. Level of exposure to HIV m personal I!/b. In terms of exposure to A I D S in their personal life, only t w o % felt that such exposure was highly p r o b a b l e and an additional 12% felt that it was slightly probable. Some 86% felt that such private life exposure was unlikely, very unlikely, or not at all possible.
Comparison of occupational and personal l!)re exposure to H1V risk. T a k e n together, HIV exposure risk data suggest the majority of nurses who reported feeling exposed to a risk of H I V infection identified the exposure as occupational rather t h a n in personal life. F o r those nurses reporting at least a slightly p r o b a b l e exposure to HIV, 78% reported it was t h r o u g h occupational exposure. O f those reporting a high probability of exposure, 90% felt the risk occurred in the occupational setting.
Source of HIV exposure risk and health care attitudes. The correlations between all four health care attitude factors and exposure in personal life was almost zero (r = 0.03 to r = 0.06). Exposure risk in personal life was then dropped from further data analyses. The relationships of reported exposure a n d health care attitudes are summarized in Table 1. Felt exposure to H I V infection risk on-the-job was significantly related to three of the four professional health attitude factors. Nurses who reported greater occupational exposure to H I V infection risk were less likely to be willing to care for HIV-infected children (r = - 0.19), and they were more likely to express fear of acquiring the infection from their patients (r = 0.34) a n d to feel that such care was futile ( r = 0 . 1 4 ) . Occupational exposure, then, was included in regression analyses of the health care attitude factors.
Relationship of attitudes to experience, exposure and other independent variables Using stepwise regression, eight i n d e p e n d e n t variables were regressed on the four health care attitude factors. I n d e p e n d e n t variables included experience caring for HIV-infected patients, reported occupational exposure, highest educational level achieved, length of time worked as a nurse, age, gender, religiosity and sexual orientation. Variables were stepped in if they were adding statistically significant (ct < 0.05) variance and added at least o n e % to the explained variance (R2). Experience and occupational exposure explained significant variability on the three health care attitude factors that h a d respectable reliability: 'willingness to care', 'fear' and 'futility' (see Table 2). O f the 24% explained variance on 'willingness to care' experience accounted for 19% with occupational exposure relating negatively to willingness-to-care and explaining an additional 5%. Regarding the 'fear' factor, nurses reporting occupational exposure were not only less willing to provide care, as noted above, but also were more fearful of infection, with occupational exposure explaining 10% of variance on the fear factor. Educational level of the nurse was significantly related to the fear factor. Education level and experience were b o t h negatively related to fear and
Table 2. Regression of independent variables on health care attitude factors Independent variables /3 R2 change Significance Willingness to care R~,~j= 0.24 F,2.47~= 7 6 . 5 4 Significance<0.0001 Experience 0.45 0.19 < 0.0001 Occupational exposure - 0.22 0.05 < 0.0001
Fear
RAdj= 0. I7 0.30 - 0.20 - 0.15
F~,75~= 3 3 . 2 5 0.10 0.05 0.02
Significance< 0.0001 _<0.0001 < 0.0001 < 0.0005
Experience Occupational exposure
R~dj= 0.05 - 0.18 0.15
F~,4;5~= 1 2 . 7 2 0.03 0.02
Significance_<0.0001 < 0.0001 < 0.0012
Distress
R~dj =
0.02 0.15
F,.,77~= 10.33 0.02
Significance~0.0014 < 0.0014
Occupational exposure Education level Experience
Futilio'
Age of nurse
Research Note together accounted for another 7% of variance. For 'futility,' experience (negatively related) and occupational exposure (positively related) together explained approx. 5% of variance. The only variable entering the regression equation for the 'distress' factor was the nurse's age, with older nurses expressing more distress. Other independent variables either did not enter into the regression equations or explained < 1% of the variability. As we expected, experience caring for HIV-infected children was not necessarily synonymous with reported risk of acquiring HIV infection on-the-job. In fact, the correlation between experience and reported exposure risk was nonsignificant and almost zero (r = 0.04). Whereas more experience was positively correlated with 'willingness-to-care' and negatively correlated with "fear' and 'futility', higher reported risk of occupational exposure was correlated in opposite directions with these attitudes. Nurses who reported higher risk of exposure to HIV infection were significantly more likely to feel fear and to feel care for HIV-infected children was futile and were less willing to provide care.
DISCUSSION In this study we sought to assess attitudes of caregivers toward HIV-infected patients while controlling for attitudes toward people engaging in high risk behaviors. We chose to study pediatric nurses caring for H IV-infected children because nurses are in the front lines of HIV care and HIV-infected children are often regarded as innocent victims. Moreover the risk of occupational infection is potentially great with this population. We looked at risks as composed of two factors, experience and exposure, and formulated two hypotheses. The first hypothesis was that pediatric nurses with more experience in caring for HIV-infected children would have more posith,e attitudes toward caring for such patients. The second was that nurses who felt they had greater occupationalexposure to risks of HIV infection, such as exposure to blood and body fluids or needle sticks, would have less favorable attitudes. Factor analysis resolved the health attitude items into four factors, and both hypotheses were upheld for three of the four factors: 'willingnessto care', 'fear' and 'futility'. The fourth factor, 'distress', was not significantly related to either experience with HIVinfected patients or occupational exposure. The correlation between the experience and exposure measures was not significant, and was in fact almost zero. Supporting the findings of Ficarrotto et al. [15] that greater experience related to less resistance toward providing care, pediatric nurses in this study who were heavily involved in serving HIV-infected patients generally had more positive and less fearful attitudes toward these patients than did nurses with less experience. The relationship between attitudes and
467
experience in this study are in contrast with reports of no significant relationship between experience and attitudes [3, 4, 16], and to a negative relationship reported by Kemppainen et al. [2]. There were several differences between our study and Kemppainen et al. including the method of measuring both experience and willingness to care. Possibly most importantly, our respondents were pediatric nurses caring tbr children while Kemppainen et al.'s respondents were employed in Veterans Administration hospitals and presumably cared for an adult population. We must note, however, that even the nurses in our study with little or no experience with HIV-infected patients did not have negative attitudes toward such patients. For the most part they did not feel that it was futile to expend medical resources on HIV-infected children, nor did these nurses feel that treating these patients was excessively distressing. In particular, very few of the nurses (1.4%) were unwilling to care for these patients. When asked if they would refuse to care for an HIV-infected child, if given the choice, only 9% of pediatric nurses in this study said they would refuse. However, 50% of primary care physicians [9], and between 45 and 65% of critical care nurses [1] would refuse to care for AIDS patients if given the choice. Bond et al. reported 26% of community nurses in England [10] and Koch et al. found 23% of rural nurses in the northeastern U.S. [4] felt they should have the right to refuse care for people with AIDS, while Campbell et al. reported 55% of hospital nurses had these feelings [11]. Our findings are more compatible with Bond et al. and Koch et al.. as 75% of our respondents felt a nurse does not have the right to refuse to care for HIV-infected children. At least in our study, where HIV-infected individuals did not have behaviors which could have led to their infections, nurses have positive attitudes toward them and are committed to their care. Those nurses who suspected they had been occupationally exposed to HIV, however, generally had more negative attitudes towards and were more likely to refuse to care for people with HIV. Our results support other researchers who have found a negative relationship between suspected HIV risk and favorable attitudes such as willingness to provide care [13, 15, 22]. In our study nurses, regardless of experience level, had a slight tendency to agree with the "fear" of occupational exposure items; but not present in this population were high levels of fear reported elsewhere [13]. Thus, while pediatric nurses in this sample can be said to have generally positive attitudes toward HIV-positive patients, they also tend to have a healthy respect for the dangers of infection and for the risks of contracting this disease. While aware of and concerned with personal risk, pediatric nurses are not seriously affected by such fears in their professional lives, In summary we found that pediatric nurses who had more experience with HIV-infected children were less
468
Research Note
afraid a n d h a d m o r e positive attitudes t o w a r d these p a t i e n t s t h a n did t h o s e nurses with less experience. T h e s e positive attitudes were reflected in a g r e a t e r willingness to care a n d a d e c r e a s e d sense o f futility in w o r k i n g with H I V - i n f e c t e d children. M o r e o v e r , m o r e t h a n h a l f the nurses in this s a m p l e r e p o r t e d that increased e x p e r i e n c e e n g e n d e r e d m o r e positive attitudes t o w a r d p e o p l e infected with H I V . While they did have realistic fears o f infection, there was n o i n d i c a t i o n that these nurses, regardless o f level o f experience, were unwilling to care for H I V - i n f e c t e d patients. W e c o n c l u d e d that w h e n the s a m p l e o f clients is a d j u s t e d to r e m o v e o t h e r biases, risk o f acquiring a fatal infection is n o t sufficient to dissuade caregivers f r o m either their positive attitudes t o w a r d p a t i e n t s o r willingness to care for them. Only f u r t h e r research will s h o w w h e t h e r these results m a y be generalizable to o t h e r p o p u l a t i o n s o f caregivers o r to o t h e r g r o u p s o f p a t i e n t s p o t e n t i a l l y h a z a r d o u s to the caregiver. REFERENCES
1. Damrosch S., Abbey S., Warner A. and Guy S. Critical care nurses' attitudes toward, concerns about, and knowledge of the acquired immunodeFIciency syndrome. Heart Lung: J. Critical Care 19, 395, 1990. 2. Kemppainen J., St. Lawrence J. S., Irizarry A., Weidema D. R., Benne C., Fredericks C. D. and Wilson M. Nurses' willingness to perform AIDS patient care. J. Continuing Educ. Nursing 23, 110, 1992. 3. Klonoff E. A. and Ewers D. Care of AIDS patients as a source of stress to nursing staff. A I D S Educ. Prevention 2, 338, 1990. 4. Koch P. B., Preston D. B., Young E. W. and Wang M. Factors associated with AIDS-related attitudes among rural nurses. Hlth Values 15, (6) 32, 1991. 5. van Servellen G., Lewis C. E. and Leake B. The limitations of generic AIDS education programs for the health professions. J. Continuing Educ. Hlth Professions 10, 223 236, 1990. 6. Dworkin J., Albrecht G. and Cooksey J. Concern about AIDS among hospital physicians, nurses, and social workers. Soc. Sci. Med. 33, 239, 1991. 7. Storosum J. G., Sno H. N., Schalken H. F. A., Krol L. J., Swinkels J. A., Nahuijs M., Meijer E. P. and Danner S. A. Attitudes of health-care workers towards AIDS at three Dutch hospitals. A I D S 5, 55, 1991. 8. Kunzel C. and Sadowsky D. Predicting dentists" perceived occupational risk for HIV infection. Soc. Sci. Med. 12, 1579, 1993. 9. Gerbert B., Maguire B. T., Bleecker T., Coates T. J. and McPhee S. J. Primary care physicians and AIDS. J. Am. Med. Assoc. 266, 2837, 1991. 10. Bond S., Rhodes T., Philips P., Setters J., Foy C. and Bond J. HIV infection and AIDS in England: the experience, knowledge, and intentions of community nursing staff. J. Adv. Nursing 15, 249, 1990. 11. Campbell S., Maki M., Willenbring K. and Henry K. AIDS-related knowledge, attitudes, and behaviors among 629 registered nurses at a Minnesota hospital: a descriptive study. J. Assoc. Nurses A I D S Care: J A N A C 2, 15, 1991. 12. Kelly J. A., St. Lawrence J. S., Smith S., Hood H. V. and Cook D. J. Stigmatization of AIDS patients by physicians. Am. J. Publ. Hlth 77, 789, 1987. 13. Ficarrotto T. J., Grade M. and Zegans L. S. Occupational and personal risk estimates for HIV contagion among incoming graduate nursing students. J. Assoc. Nurses A I D S Care: J A N A C 2, 5, 1991.
14. Kelly J. A., St. Lawrence J. S., Hood H. V., Smith S. and Cook D. J. Nurses' attitudes toward AIDS. J. Continuing Educ. Nursing 19, (2) 78, 1988. 15. Ficarrotto T. J., Grade M., Bliwise N. and Irish T. Predictors of medical and nursing students' levels of HIV-AIDS knowledge and their resistance to working with AIDS patients. Acad+ Med. 65, 470, 1990. 16. Forrester D. A. and Murphy P. A. Nurses" attitudes toward patients with AIDS and AIDS-related risk factors. J. Adv. Nursing 17, 1260, 1992. 17. Meisenhelder J. B. Contributing factors to fear of HIV contagion in registered nurses. IMAGE: J. Nursing Scholarship 26, 65, 1994. 18. Denker A. L. Nursing care of children with acquired immunodeficiency Syndrome: A grounded theory approach. Unpublished Doctoral Dissertation, University of Miami, Coral Gables, FL, 1989. 19. Novick A. What are the responsibilities of HIV-infected persons? What are the reciprocal responsibilities of society? A I D S Publ. Policy J. 9, 55, 1994. 20. H I V / A 1 D S Surveillance Report, Year End Edition, Vol. 5. Centers for Disease Control and Prevention, Atlanta, GA: U.S. Dept. of Health and Human Services, 5(4), 1994. 21. Ruane B. A. and Conlon M. Recruitment and retention strategies tot an AIDS unit. Recruitment Retention Rep. 5, (9) 1, 1992. 22. Jemmott J. B. 1., Freleicher J. and Jemmott L. S. Perceived risk of infection and attitudes toward risk groups: determinants of nurses' behavioral intentions regarding AIDS patients. Res. Nursing Hlth 15, 295, 1992. 23. Festinger L. ,4 Theo O, ~1 Cognitive Dissonance. Row-Peterson, Evanston, IL, t957. 24. Berkowitz N. F. Nurses' attitudes toward caring for HIV-infected children. 1993. Unpublished Doctoral Dissertation, Boston College, Chestnut Hill, MA. 25. Cattell R. B. The scree test for the number of factors. Multh,ariate Behat,. Res. 1,245+ 1966. 26. DeVellis R. F. Scale development theory and applications. Applied Social Research Methods Series (Edited by Bickman L. and Rog D. J.), Vol. 26. Sage Publications, Newbury Park, 1991.
APPENDIX H e a l t h care attitude J a c t o r s i. Willingness to care, ~ = 0.84, mean = 5.88, SD = 0.6
If given the choice, Fd refuse to care for an HIV-infected child. (reversed) 1 would have to overcome a lot of my own resistance to care for an HIV-infected child. (reversed) I can't bear caring for HIV-infected babies. (reversed) I try not to touch my HIV-infected patients. (reversed) I interact with HIV-infected patients as much as I interact with my other patients. I would provide care for an HIV-infected child. I would find caring for an HIV-infected child deeply satisfying. I can't imagine a child I'd less like to care for than an HIV-infected child. (reversed) I just cannot let myself get attached to an H1V-infected child. (reversed) I feel well enough informed about HIV infection to care for these patients. No one really knows how "at risk" nurses or physicians are to get AIDS from HIV-infected patients. (reversed) I don't think I can stand to see another HIV-infected child. (reversed) A nurse has the right to refuse to care for an HIV-infected patient. (reversed)
Research Note 1 feel confident that adhering to infection control guidelines and precautions will protect me from contracting HIV. A physician has the right to refuse to care for an H1V-infected patient. (reversed) 2.
F e a r , ~: = O. 74, m e a n
= 4.46, SD
= 1.2
It's hard to take care of any infant without worrying about getting infected with HIV. I often think of myself as 'at risk' for HIV. 1 just don't worry about getting HIV from my patients. (reversed) tt IV has caused nursing to become a 'high risk' occupation. I rarely think of HIV exposure at my workplace. (reversed) In my specialty, there's little risk of exposure to HIV. (reversed) Every time I see a newborn baby I think "this baby might be HlV-infected." 3.
Futility,
~ = O. 75, m e a n
:= 2 , 3 7 ,
SD = 2.2
There's not much point in pouring out precious medical resources for HIV-infected children. Families with HIV infection are n o t capable of complying with health care routines, Families with HIV-infected children don't want the health care 1 have to offer. Morns of HIV-infected infants don't pay much attention to medical follow-up for their babies.
SSM 42/3--L,
469
Parents of HIV-infected children are likely to be on drugs, the streets or dead. Parents of HIV-infected children are too psychologically fragile, The last thing I want is for a drug-using HIV-infected mother to tell me how to care for her child. I don't enjoy working with low-income minority families. There's n o t much we can do to decrease the spread of HIV in drug abusing women. Abortion is the best option for a pregnant HIV-infected woman. 4. D i s t r e s s ,
~ = 0.62, mean
= 4 . 1 9 , S D = 1.0
I feel overwhelmed when both a mother and her child have a fatal disease. Working with H1V-infected children is tense--like waiting for the other shoe to drop. 1 can't stand wondering whether or not an HIV positive baby is really HIV-infected. People don't understand how much harder it is to care for a mother or her child when both are dying of HIV infection. Caring for HIV-infected children means you're up to your eyeballs with work. I always want to help the underdog. I don't think of 'if' HIV-infected children will die but "when' they will die. I wish l could be the one to make care decisions for HlV-infected children.